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1、PLANT POISONING in Critical Care,林秉熙 醫師 新光醫院腎臟科主治醫師 國立陽明大學醫學系講師,Lin B.S.,2,Key Points (1),There are a large variety of plant poisons in nature with only few specific antidotes. Acute gastroenteritis is a feature of most plant poisonings. Organic brain syndromes are common. Supportive care and decont
2、amination (gastro-intestinal tract and others) are the mainstays of treatment.,Lin B.S.,3,Key Points (2),Identification of the plant is important for anticipating clinical events. In plant-related cardiac glycoside toxicity, antidigoxin Fab fragments may be of use. Mucosal irritation, renal failure,
3、 and hypo-calcemia characterize plant-related oxalate toxicity.,Lin B.S.,4,Key Points (3),Life-threatening mushroom poisonings tend to have a delay of at least 6 h prior to the onset of symptoms. Hepatic, renal, or central nervous system complications may develop, depending on the type of mushroom i
4、ngested,Lin B.S.,5,Hindered plant toxicology,Paucity of acutely ill patients, prospective clinical trials, and good clinical series in plant toxicology Immense number of uncharacterized potential toxins in the plant kingdom Imprecise identification of the offending species Identification of the toxi
5、n or quantitative blood levels rarely obtained,Lin B.S.,6,Benign plants with acute illness,Simultaneous ingestion of pesticides Allergic response,Lin B.S.,7,Common clinical syndromes,Acute gastroenteritis Almost universal, even the only feature of poisonings Organic brain syndrome the second most co
6、mmon manifestation often seen along with, or following the gastroenteritis alteration in mental status manifested by delirium, coma, or seizures,Lin B.S.,8,General Management,Stablized airway, breathing & circulation Naloxone & dextrose for altered mentation Gastrointestinal decontamination with lav
7、age and activated charcoal Identifying the plant Consultation with regional poison control center Specific antidote if available,Lin B.S.,9,Specific Plant Syndromes (1),ANTICHOLINERGIC SYNDROME PYRROLIZIDINE ALKALOIDS CARDIAC GLYCOSIDE OXALATE SYNDROME SOLANINE ALKALOIDS NICOTINE ALKALOID CYANOGENIC
8、 PLANTS,Lin B.S.,10,Specific Plant Syndromes (2),TOXALBUMIN-CONTAINING PLANTS COLCHINE POISONING MISTLETOE (槲寄生) TOXICOLOGY PODOPHYLLUM (鬼臼樹脂) POISONING PENNYROYAL (薄荷) OIL EUCALYPTUS (桉樹) OIL HALLUCINOGENIC PLANTS,Lin B.S.,11,Specific Plant Syndromes (3),AKEE FRUIT POISONING TAXINE (YEW) POISONING
9、FAVA BEAN POISONING WATER HEMLOCK (毒水芹) POISONING RHODODENDRON (杜鵑花) POISONING DAPHNE (月桂) POISONING GASTROENTERITIS SYNDROME MUSHROOM POISONING,Lin B.S.,12,Anticholinergic Syndrome,Deadly nightshade (Atropa belladonna 顛茄) Angels trumpet (Datura suaveolens 曼陀羅) Jimson weed (D. stramonium) Matrimony
10、vine (Lycium halimifolium) Henbane (Hyoscyamus niger 茛菪),Lin B.S.,13,Anticholinergic syndrome (ACS),Tropane alkaloids atropine (顛茄鹼) scopolamine (茛菪鹼) The most common plant causes Datura stramonium (jimson weed, 曼陀羅) Atropa belladonna (deadly nightshade,茛菪),Lin B.S.,14,Anticholinergic syndrome (ACS)
11、,The most frequent cause of intoxication by these plants is from teas. Anticholinergic plant poisoning is occasionally induced purposefully in an attempt to capture the hallucinogenic anticholinergic effects.,Lin B.S.,15,Anticholinergic syndrome (ACS),Toxicities: competitive antagonist at the cholin
12、ergic-muscarinic receptor. Cross the blood-brain barrier, cause central effects Clinical pictures: “mad as a hatter, hot as a bare, dry as a bone, red as a beet, and blind as a bat “,Lin B.S.,16,Anticholinergic syndrome (ACS),Tachycardia: usually sinus supraventricular as well as ventricular arrhyth
13、mias may occur. Profound alteration in mentation: including confusion, agitation, disorientation, hallucinations, and seizures.,Lin B.S.,17,Physical examination,Mydriasis, absence of perspiration, and relatively parched mucous membranes Flushed due to peripheral cutaneous dilation Fever is common.,L
14、in B.S.,18,Treatment of ACS,Observed for cardiac dysrhythmias, hemodynamic instability, agitation, and seizures. Benzodiazepines for significant agitation Potential antagonist: Physostigmine may result in bradydysrhythmias, asystole, or seizures restricted to patients with life-threatening ACS, or d
15、iagnostic dilemmas,Lin B.S.,19,Administeration of physostigmine,Usual dose of physostigmine: 2 mg (0.5 mg for pediatric patients) intravenously over at least 2 min. A syringe containing atropine standby Contraindications: asthma, peripheral vascular disease, bowel obstruction, urinary tract obstruct
16、ion, or gangrene.,Lin B.S.,20,CARDIAC GLYCOSIDES,Christmas rose (Helleborus niger 黑藜蘆) Lily of the Valley (Convallaria majalis 歐鈴蘭) Foxglove (Digitalis purpurea 毛地黃) Common oleander (Nerium oleander 夾竹桃) Yellow oleander (Thevetia sp.),Lin B.S.,21,Cardiac glycosides (1),The presentation of plant card
17、iac glycoside poisoning is similar to medicinal glycosides. There is an initial period of gastrointestinal discomfort followed by multiple cardiac conduction abnormalities and hyperkalemia.,Lin B.S.,22,Cardiac glycosides (2),Foxglove plant (Digitalis purpurea 毛地黃) contains predominantly digitoxin lo
18、ng half-life and prolonged clinical syndrome European snapdragon 金魚藻 (Digitalis lanata) contains mostly digoxin causes a more abbreviated syndrome,Lin B.S.,23,Cardiac glycosides (3),Variable degree of cross-reactivity Digoxin levels unreliable Bind to activated charcoal: Multiple doses of activated
19、charcoal indicated Digitoxin: a true enterohepatic circulation Efficacy of antidigoxin Fab fragments: Controversy,Lin B.S.,24,Pyrrolizidine Alkaloid Syndrome,Threadleaf (Senecio longilobus 劉寄奴草) Heliotrope (Heliotropium europaeum 天芥菜) Russian comfrey (Symphytum xuplandicum 紫草) Horsefoot (Tussilage f
20、arfara 款冬),Lin B.S.,25,Pyrrolizidine alkaloids (1),First recognized in 1954 in Jamaica hepatic veno-occlusive disease related to drinking herbal teas or eating contaminated cereals. Endothelial edema of small and medium size hepatic veins and venules, result in sclerosis and occlusion.,Lin B.S.,26,P
21、yrrolizidine alkaloids (2),Congestion of hepatic sinusoids and central veins centrilobular hemorrhagic necrosis large hepatic veins unaffected, distinguishing from the Budd-Chiari syndrome. Typicall presentation: RUQ abdominal pain, nausea, vomiting, diarrhea, hepatomegaly, splenomegaly, ascites, ja
22、undice, hypoglycemia, and extremely high GOT/GPT,Lin B.S.,27,Pyrrolizidine alkaloids (3),Chronic ingestion progressive hepatic veno-occlusive disease cor pulmonale No specific antidote Treatment: supportive management of coagulopathy, hypoglycemia, pulmonary hypertension, and encephalopathy,Lin B.S.
23、,28,Oxalate Syndrome,Dumbcane (Dieffenbachia sp.) Elephants ear (Colocasia antiquorum) Rhubarb (Rheum sp. 大黃) Jack-in-the-pulpit (Arisaema atrorubens 美國黃花菖蒲) Skunk cabbage (Symplocarpus foetidus 臭菘) Swiss cheese plant (Monstera sp.) Philodendron (Philodendron sp. 黃蘗) Caladium (Caladium bicolor 貝母),L
24、in B.S.,29,Oxalate syndrome (1),Primary syndrome: mucosal irritation Most common cause: Dieffenbachia Chronic ingestion of rhubarb leaves (大黃) Soluble vs. insoluble (rhaphides) form,Lin B.S.,30,Oxalate syndrome (2),Rhaphides: severe mucosal irritation, even laryngeal edema Soluble oxalate: systemic
25、& diffuse effect Mucosal irritation gastroenteritis renal failure hypocalcemia,Lin B.S.,31,Oxalate syndrome (3),Treatment Maintain airway Oral fluid, preferably milk for dilution ECG & serum calcium monitoring Hemodynamic monitoring Adequate fluid supply & monitor renal function,Lin B.S.,32,Solanine
26、 Alkaloid Syndrome,Jerusalem cherry (Solanum pseudo-capsicum) Common potato (S. tuberosum 馬鈴薯) Eggplant (S. melongena 茄子) Woody nightshade (S. dulcamara) Horse nettle (S. carolinense 針茄) Common nightshade (S. nigrum) Tomato (Lycopersicon esculentum) Trumpet flower (Solandra sp.),Lin B.S.,33,Solanine
27、 alkaloid (1),Most plants of the Solanaceae family (nightshade 茄屬 or potato plants 馬鈴薯) contain the solanine alkaloids in nontoxic amounts. Severe solanine alkaloid poisoning can occur when potatoes are harvested while still green, are improperly stored, or are traumatized.,Lin B.S.,34,Solanine alka
28、loid (2),Toxicities: Gastrointestinal tract irritation Gastric juice hydrolyze solanine alglycon & sugar Aglycone: hypotension & organic brain syndrome Solanocapsine toxicity: cardioinhibitory syndrome, with both negative inotrophic/chronotrophic effect Superimposed ACS,Lin B.S.,35,Solanine alkaloid
29、 (3),Treatment Supportive measures Gastrointestinal decontamination: activated charcoal Treat superimposed ACS,Lin B.S.,36,Nicotine Syndrome,Tobacco (Nicotiana sp. 菸草) Poison hemlock (Conium maculatum 毒人蔘) Indian tobacco (Lobelia inflata 半邊蓮),Lin B.S.,37,Nicotine alkaloid-containing plants,Poisoning
30、 when used as purgatives and enemas Hemlock (毒芹) root: confused with wild carrots Leaves: similar in appearance to parsley (荷蘭芹),Lin B.S.,38,Nicotine alkaloid-containing plants,Toxicity Rapid emesis due to direct effect and stimulation of medullary chemoreceptor trigger zone Stimulate postsynaptic r
31、eceptors of autonomic neurons and motor end plates Initial stimulation followed by depression, either sympathomimetic or cholinergic Death within an hour of ingestion (respiratory failure),Lin B.S.,39,Nicotine alkaloid-containing plants,Treatment Thorough skin decontamination Activated charcoal in m
32、ultidose fashion Respiratory and hemodynamic monitoring,Lin B.S.,40,Cyanogenic Glycosides Syndrome,Common fruit pits (Rosaceae family) Cherry laurel (Prunus laurocerasus 月桂櫻桃) Cassava (Manihot esculenta 樹薯) Bamboo (Phytostachys aurea 竹子) Elderberry (Sambcucus sp. 接骨木) Bitter almonds (Prunus dulcis 苦
33、杏) Hydrangea (Saxifragaceae family 繡球花) Lima beans (Phaseolus lunatus 青豆) Chokecherry (Prunes airginiana 苦櫻桃),Lin B.S.,41,Cyanogenic plants (1),Cyanide: One of the most potent and rapid acting poisons Widely distributed in the plant world in the form of cyanogenic glycosides (sugar compounds of cyan
34、ide) Glycosides may be hydrolyzed by either plant enzymes simultaneously ingested or endogenous enzymes to liberate hydrogen cyanide,Lin B.S.,42,Cyanogenic plants (2),Amygdalin (苦杏仁素) The most common glycoside, also found in plum, peach, apricot, bitter almond, cherry, pear, and apple The major glyc
35、oside in the product sold as Laetrile These pits contain a complex of enzymes known as emulsin in their coats. When the pits are chewed, emulsin is liberated and metabolizes the nontoxic amygdalin to free hydrogen cyanide.,Lin B.S.,43,Cyanogenic plants (3),Linamarin: another common cyanogenic glycos
36、ide found in lima and cassava beans Tropical or Nigerian ataxic neuropathy: Chronic cassava consumption in tropical areas, particularly Nigeria, associating with chronic cyanide poisoning,Lin B.S.,44,Cyanogenic plants (4),Diagnosis: Based primarily on a high index of suspicion Hypotension, seizures,
37、 an altered mental status, or a persistent metabolic acidosis in the setting of the potential ingestion of cyanogenic plants Odor of bitter almonds is a further clue but unreliable; cannot be detected by up to 40 % of the population.,Lin B.S.,45,Cyanogenic plants (5),Treatment of cyanide poisoning P
38、rompt resuscitation Ventilation with 100 % oxygen Sodium thiosulfate, 25 % solution, 150 mg/kg iv Gastric decontamination (larvage) Activated charcoal administration,Lin B.S.,46,Toxalbumin Syndrome,Castor bean (Ricinus communis 蓖麻子) Jequirity bean (Abrus precatorius 相思子) Sandbox tree (Hura crepitans
39、) Bellyache bush (Jatropha gossipifolia 麻風樹屬) Black locust (Robinia pseudoacacia 北美刺槐樹) Desert potato (J. macrorhiza),Lin B.S.,47,Toxalbumin-containing plants,Abrin, the active toxin in the jequirity bean, and ricin, found in the castor bean, are among the most potent natural toxins known when admin
40、istered parenterally. Ingestion of these beans is usually not associated with toxicity unless they are chewed. Extremely antigenic, causing a hypersensitivity reaction,Lin B.S.,48,Toxalbumin-containing plants,Castor bean toxicity: acute, severe, gastroenteritis Jequirity bean contains glycyrrhizin,
41、which may cause hyperaldosteronism. Abrin is more toxic than with ricin “as little as one jequirity bean when chewed can be lethal to a child”,Lin B.S.,49,Toxalbumin-containing plants,Toxic effects of toxalbumin ingesion: acute, persistent and severe gastroenteritis encephalopathy: stupor, seizures,
42、 and coma multiple organ system failure in some cases, with pancreatitis, hepatotoxicity, hemolysis, renal failure. In addition, a primary irritant dermatis,Lin B.S.,50,Toxalbumin-containing plants,Treatment: Standard supportive care Activated charcoal administration Treat severe hemorrhagic gastroe
43、nteritis No specific antidote available,Lin B.S.,51,Colchicine Syndrome,Autumn crocus (Colchicum autuminate) Glory lily (Gloriosa superba),Lin B.S.,52,Colchicine poisoning,True botanical colchicine poisoning is unusual. The clinical syndrome: acute gastroenteritis, may be severe & hemorrhagic ascend
44、ing motor paresis, bone marrow depression, rhabdomyolysis, renal failure, DIC, and ARDS, which is usually the cause of death Organic brain syndrome: seizures and delirium.,Lin B.S.,53,Colchicine poisoning,Atropine: antidotal to the gastrointestinal effects Activated charcoal should be administered m
45、ultidoses of charcoal due to ileus in many patients Anticipate rhabdomyolysis and renal failure circulatory shock direct nephrotoxic effects of the colchicine Central venous or Swan-Ganz monitoring if needed,Lin B.S.,54,Mushroom poisoning,Mushroom-induced toxic syndromes: 8 groups Three life-threate
46、ning mushroom syndromes: Hepatorenal syndrome, central nervous system abnormalities, renal failure causative agents: cyclopeptides, monomethyl-hydrazine, orelline, and orellanine,Lin B.S.,55,Mushroom poisoning,Specific management prolonged multiple-dose activated charcoal therapy high-dose penicilli
47、n G may be hepatoprotective ? transplantation for fulminant amatoxin-induced hepatic failure ? Monomethylhydrazine poisoning: administration of methylene blue for significant methemoglobinemia treatment of seizures with pyridoxine,Lin B.S.,56,Acute Gastroenteritis,Holly berries (Illex sp. 冬青) Pokeweed (Phytolaccia americana ) (北美商陸木) English ivy (Hedera helix 長春藤) Aloe vera 蘆薈 Multiple bulbs,Thank You for Your Attention,終於結束了 ,